Morning Report

Post-Operative Fever
June 1, 2004

Jennifer Caffey,
D.O.
HPI
• CC: Fever x 2 days
• HPI: 19 months old female with 2 days
history of fever, max. 102F. Emesis
x2, described as non-bilious, non-bloody.
Appetite decreased but tolerating oral
fluids. Good urine output. No sick
contacts. Status-post Open
Reduction, Internal Fixation 5 days prior to
admission for developmental dysplasia of
the left hip.
Review of Systems

• No URI symptoms
• No pain in extremities
• No dyspnea
• No chest pain
• No diarrhea, no
constipation
• No rashes
Past History

• PMH: developmental dysplasia of left hip

• PSH: 2 prior corrective surgeries on left hip, 1st
on May 6, 2nd on May 20, 2004
• Birth: term AGA female born via C-
section secondary to hand presentation.
Pregnancy complicated by transient episodes
of maternal hypotension. Normal nursery stay.
History (cont)

• Previous Hospitalizations: 9 mos

for febrile illness. Twice in May 2004
for hip surgery.
• Meds: Tylenol prn fever
• Allergies: NKDA
• Immunizations: UTD by history
• Diet: well rounded, age-appropriate
History (cont)

• Family Hx: Maternal grandmother

with Type II DM
• Social Hx: Lives with mom, dad,
5y/o brother and 2m/o brother.
Dad is a smoker. + Cats outside.
No daycare.
• Developmental: Speaks Spanish
only, multiple single words
Physical Exam
• V/S: T 37.3 (ax) HR 145 RR 24
BP: 103/53 Wt: 15kg (>95th )
• Gen: Lying on back in SPICA cast
• HEENT: normocephalic, PERRL, red
reflex intact, nares patent, TM’s clear
Bilaterally, moist mucosa, oropharynx
with mild erythema, no cervical
lymphadenopathy
• Heart: regular rhythm, no murmurs
Physical Exam (cont)
• Lungs: Limited exam secondary to cast, upper
lobes clear to auscultation bilaterally
• Abd: Limited secondary to cast, + bowel sounds,
lower abdomen soft, not tender
• Ext: lower extremities in cast, lower extremity
pulses 2+ and symmetrical
• Neuro: Limited exam, no focal deficits
• GU: normal female genitalia, left hip wound
dressed and without drainage.
LABS (initial)

• CBC: WBC 15.6 H/H 8.6/27.2

G 69.5 L 19.6 M 10.4 E 0.2 B 0.2
Platelets 459,000
• Blood Culture -- drawn
• CXR: Lungs are clear except for
some increased opacity behind the
heart that may represent atelectasis.
Labs during Hospital
Stay
• ESR 98 (5/26), repeat 78 (5/28)
• CRP 10.2 (5/26), repeat 2.1
(5/28)
• Blood Culture negative at 73
hours
Differential Diagnosis

• UTI
• Wound infection/abscess
• Pneumonia
• Vascular/venous catheters
• Deep vein thrombophlebitis
• Others…?
Postoperative Fever

• Fever > 38° is common in 1st few

days after major surgery
• Most early post-op fever caused by
inflammatory stimulus of surgery
and resolves spontaneously
Postoperative Fever
(cont)
•Pathophysiology of fever:
- Fever is manifestation of cytokine release
in response to stressful stimuli
- Cytokines released include interleukin-1,
TNF-alpha, IFN gamma
- Fever-associated cytokines released by
tissue trauma and do not necessarily signal
infection
Postoperative Fever
(cont)
• Timing of fever after surgery is important in
establishing differential diagnosis:
- Immediate - onset in operating suite or within
hours after surgery
- Acute- onset within 1st week after surgery
- Subacute - onset from 1 to 4 weeks after
surgery
- Delayed – onset >1 month after surgery
Post-op Fever- Immediate
Differential Diagnosis:
• Medications or blood products,
• Immune mediated reactions to
transfused blood products and
antimicrobials, and
• malignant hyperthermia
Fever due to trauma of surgery resolves
within 2-3 days (fever due to severe
head trauma may be persistent and not
resolve for days to weeks)
Post-op Fever- Acute

Differential Diagnosis:
• Nosocomial infections
• Community acquired infections
• Surgical site infection
• Intravascular catheters
• Pneumonia
• UTI
Post-Op Fever- Subacute
Differential Diagnosis:
• Surgical site infection
• Central venous catheter related
infections
• Thrombophlebitis
• Antibiotic associated diarrhea
• Drug Fever
• Deep Vein Thrombophlebitis
• Pulmonary Embolism
Post-Op Fever- Delayed

Differential Diagnosis:
• Infection
• Viral infections from blood
products
• Surgical site infections
Causes of Post-op Fever
• Infectious:
Surgical site
infections
Pneumonia
UTI
Catheter infection
Sinusitis
Meningitis
Parotitis
TSS
Causes of Post-op Fever

• Non-Infectious:
Stress of surgery
Medications
Malignant hyperthermia
Deep vein thrombosis
Fat embolism
Transfusion reactions
Atelectasis?
Orthopedic Procedures

Complications:
Spontaneously resolving fever is the rule
after major orthopedic surgery
Differential Diagnosis:
• Surgical Site Infections
• Hematoma
• Deep Vein Thrombosis/Thrombophlebitis
Approach to Patient
• Evaluate patient systemically taking
into account timing of onset of fever
and the various possible causes
• Initial screen:
– Wind,
– Water,
– Wound,
– What did we do ?
Approach to Patient
(cont)
• Wind: consider pulmonary causes including
pneumonia, aspiration, embolism
• Water: consider UTI
• Wound: consider surgical site infection
• What did we do ?: consider treatment
interventions including medications, blood
product transfusions, and intravascular, urethral,
nasal and abdominal catheters
Treatment

• Remove unnecessary treatments

including medications and catheters
• Suppress fever with tylenol
• Antibiotics per clinical
judgment/culture results